Drug treatment of encephalopathy associated with fulminant liver failure

Hepatic encephalopathy is a complex neuropsychiatric syndrome that may complicate either chronic or acute liver failure. Hepatic encephalopathy associated with fulminant liver failure is characterised by the development of cerebral oedema and intracranial hypertension, and has a poor outcome in severe cases if liver transplantation is not performed. Medical management of hepatic encephalopathy in fulminant liver failure is essentially directed toward the prevention and treatment of cerebral oedema and intracranial hypertension. Mannitol infusion should remain the main pharmacological treatment of cerebral oedema. Despite a lack of randomised clinical trial data, thiopental (thiopentone) has been widely accepted as an effective means of treating intracranial hypertension when mannitol fails. Acetylcysteine seems to have a beneficial effect by improving the cerebral blood flow and the cerebral metabolic rate for oxygen. The effectiveness of lactulose is well established in chronic hepatic encephalopathy but not in fulminant liver failure. As the precise pathogenesis of hepatic encephalopathy in patients with fulminant liver failure is unknown, there is no specific treatment of this syndrome. In spite of a large number of published articles on the treatment of hepatic encephalopathy, only a few randomised, controlled studies are available. Indeed, except for the rare cases in which treatment of the underlying cause of disease is possible, the treatment of patients with fulminant liver failure is currently emergency liver transplantation.